Field Application Will Only Be Accepted in Typed Format

SCHOOL OF SOCIAL WORK

STUDENT FIELD PRACTICUM APPLICATION

FIELD APPLICATION WILL ONLY BE ACCEPTED IN TYPED FORMAT

CLASSIFICATION

/

TYPE OF PRACTICUM

/

ATTENDING CLASSES

______BSW
______FIRST YEAR MSW
______SECOND YEAR MSW/ OR
ADVANCED STANDING
____Government Non Profit Management
____Clinical Practice
____Bilingual/Bicultural Clinical Practice / ______Concurrent (Fall/Spring)
20___20____
______CONCURRENT (Sp/Summer)
20___/20___
______Block (Summer)
20___ / ____ LAS VEGAS
____ RIO RANCHO
____ALBUQUERQUE
____ FARMINGTON
____ ROSWELL
____SANTA FE

NAME______ID#______E-Mail Address ______

Mailing Address______

Home Telephone ______/______/______Work/Cell Telephone ______/______/______

In order of preference, rank 1-3 the communities in which you would like to complete your practicum. Return the field practicum application along with an updated resume to the contact site indicated for your area of preference.
RIO RANCHO/ABQ OFFICE-CONTACT SITE FOR:
[ ] Mescalero
[ ] Rio Rancho
[ ] Bernalillo
[ ] Albuquerque
[ ] Edgewood
[ ] Los Lunas
[ ] Cuba
[ ] Other ______
NMHU School of Social Work @ Albuquerque,
5041 Indian School Road NE, Albuquerque, NM 87110
(505) 260-6190 or (505) 260-6182 / LAS VEGAS OFFICE- CONTACT SITE FOR:
[ ] Tucumcari
[ ] Las Vegas
[ ] Espanola
[ ] Raton
[ ] Mora
[ ] Springer
[ ] Taos
[ ] Los Alamos
[ ] Santa Fe
[ ] Alamogordo
[ ] Other ______
[ ] Colorado (Name of city) ______
[ ] Texas (Name of city) ______
New Mexico Highlands University, School of Social Work,
P.O. Box 9000, Las Vegas, NM 87701
(505) 454-3294 or 3326
ROSWELL OFFICE-CONTACT SITE FOR:
[ ] Artesia
[ ] Carlsbad
[ ] Clovis
[ ] Roswell
[ ] Portales
[ ] Hobbs
[ ] Other ______
NMHU in Partnership with ENMU-R, School of Social Work,
P.O. Box 6000, Roswell, NM 88202
(575)-624-7458
FARMINGTON OFFICE- CONTACT SITE FOR:
[ ] Farmington[ ] Arizona (Name of city) ______
[ ] Shiprock
[ ] Gallup [ ] Other______
NMHU in Partnership with San Juan College, School of Social Work, 4601 College Blvd., Farmington, NM 87402
(505) 566-3047 or (505)566-3552
CONCURRENT FIELD PRACTICUMREQUIREMENTS

Sixteen hours a week of practicum.

Completion of field practicum at the same agency for both fall and spring semesters or spring/summer semesters.

Formal written approval prior to beginning field practicum.

Registrationin both Field Practicum and Field Seminar (if required for classification).

SUMMER BLOCK FIELD PRACTICUM REQUIREMENTS

Block placement approval is tentative until student provides verification that all of the required coursework for the academic year have been successfully completed. If student is not approved for a block placement, student will be required to enter into a concurrent placement.

Forty hours a week of practicum.

Completionof field practicum at the same agency for approximately thirteen weeks.

Formal written approval prior to beginningfield practicum.

Registration in (2) Field Practicum courses and Field Seminar course(s)(if required for classification).

A block practicum is requested for the following reason(s): ______

Describe the type of practicum experience you are interested in obtaining and why.

Describe the strengths you will bring to the practicum setting and identify areas of improvement you will address

during your practicum placement.

Indicate any language(s) other than English, in which you are fluent.

______[ ] Written [ ] Oral

______[ ] Written [ ] Oral

If you believe you require accommodations to successfully complete your practicum, please discuss below. ____N/A

Briefly describe any circumstances that limit your ability to travel (medical, child care needs, etc.) _____N/A

DISCLOSURE OF DISCIPLINARY HISTORY

Name ______Academic Year 20_____

1. Have you ever been suspended, expelled, placed on probation or otherwise disciplined by any college or university?

______Yes ______No

1. Have you withdrawn from, or been asked to withdraw from a field placement program?

______Yes ______No

1. Has any professional licensing authority ever taken formal disciplinary action against you?

______Yes ______No

1. Have you ever been terminated, placed on probation or disciplined by an employer for misconduct in

the performance of your duties?

______Yes ______No

1. Have you ever been the subject of an investigatory proceeding initiated by a child welfare authority concerning the alleged abuse or neglect of a child or adult?

______Yes ______No

6. Have you ever been accused of sexual misconduct or any professional impropriety?

______Yes ______No

7. Within the last 12 months, has any claim or suit been brought against you for alleged malpractice or professional

liability or are you aware of any incidents or existing circumstances that might reasonably lead to a claim or a suit?

______Yes ______No

If you answered yes to any of the questions, please explain circumstances in detailbelow and provide any supporting documentation.

I understand that I must disclose any disciplinary history to the agency instructor that agrees to provide field instruction, and that the Field Director/Coordinators will confirm with the agency instructor that the information has been disclosed.

Failure to disclose history or falsification of pertinent information violates the Social Work Code of Ethics and will be

considered behavioral misconduct under the NMHU Code of Conduct and the School of Social Work Field Policy

Manual and may result in expulsion from the School of Social Work.

I verify that the information provided is factual. I agree to cooperate in providing and obtaining additional information

as requested by the School of Social Work. I acknowledge that eligibility for social work licensure is a matter in the sole discretion of each state’s licensing board and it is my responsibility to investigate upon graduation.

______

Student Signature Date

Name ______Academic Year 20_____

1. Do you have a history of felony and/or misdemeanor convictions? ______Yes ______No

2. Have you ever been convicted of, pled guilty or no contest or forfeited bail with respect to a felony or misdemeanor

charge?

______Yes ______No

If you answered YES to questions 1 and/or 2, complete all sections below. If you answered NO to questions 1 and 2, skip to the signature section.

NAME THAT YOUR
CHARGE APPEARS UNDER / DATE OF BIRTH / DATE OF INCIDENT / CHARGE
(MISDEMEANOR/FELONY) / STATE IN WHICH YOUR MISDEMEANOR AND/OR FELONY OCCURRED

3. Explain the disposition of the charge. This entails providing a detailed narrative account of the charge and the outcome.

Date charge(s) resolved ______

4. As a future social worker, how will you utilize this experience in a positive manner?

5. As a future social worker, how will you protect yourself and the clients you work with?

I understand that I must disclose any misdemeanor and/or felony history to the agency instructor that agrees to provide field instruction, and that the Field Director/Coordinators will confirm with the agency instructor that the information has been disclosed.

Failure to disclose history or falsification of pertinent information violates the Social Work Code of Ethics and will be

considered behavioral misconduct under the NMHU Code of Conduct and the School of Social Work Field Policy

Manual and may result in expulsion from the School of Social Work.

I verify that the information provided is factual. I agree to cooperate in providing and obtaining additional information

as requested by the School of Social Work. I acknowledge that eligibility for social work licensure is a matter in the sole discretion of each state’s licensing board and it is my responsibility to investigate upon graduation.

______

Student Signature Date

I verify that I have successfully completed pre-requisite or co-requisite course work for field placement.

I understand that failure to have successfully completed any prerequisites necessary for field practicum will lead to automatic withdrawal from field practicum until requirements are met.

I understand that if my field practicum is terminated for any reason and I am placed in a new setting, information pertinent to the termination of the initial practicum will be shared in writing with my new agency instructor.

I hereby authorize New Mexico Highlands University School of Social Work to release the information provided in the field placement application and any previous field practicum records to potential field placement agencies as needed.

______

Student Signature Date

SECOND YEAR/ OR ADVANCED STANDING MSW STUDENTSIGNATURESECTION

I understand that if my field practicum is terminated for any reason and I am placed in a new setting, information pertinent to the termination of the initial practicum will be shared in writing with my new agency instructor.

I hereby authorize New Mexico Highlands University School of Social Work to release the information provided in the field placement application, resume, and any previous field practicum records to potential field placement agencies as needed.

______

Student Signature Date

FIELD OFFICE USE ONLY
______APPROVED ______NOT APPROVED TO REGISTER FOR FIELD PRACTICUM
Reason(s) for disapproval ______
______
______
______
______
Field Director/Coordinator Signature Date

Online Document Link 2304 Rev 11/1/12